presentation on acute liver failure

1. ACUTE LIVER FAILURE
MODERATOR-DR.BALA SUBRAHMANYAM
SPEAKER – DR.GANGA BHAVANI

2. CONTENTS
• DEFINITION
• CLASSIFICATION
• INCIDENCE
• PATHOPHYSIOLOGY
• ETIOLOGY
• DIAGNOSIS
• TREATMENT
• COMPLICATIONS
• PROGNOSIS
• LIVER SUPPORT DEVICES

3. DEFINITION
• Evidence of coagulation abnormalities (international normalized ratio [INR]
>1.5) and mental alterations (encephalopathy) of a patient without
preexisting cirrhosis and <26 weeks of illness duration .

4. CLASSIFICATION

5. MCC of ALF in India ?

8. ETIOLOGY

9. ACETAMINOPHEN HEPATOTOXICITY
• Acetaminophen toxicity when dose > 10gm/day(150mg/kg).
• Metabolism – 95% by hepatic conjugation and 5% converted to NAPQI
• NAPQI – Inactivated by glutathione and excreted rapidly.
• What happens in overdose ?
• Lesser doses cause toxicity in chronic alcoholic patients and individuals on drugs
that induce cytP450 enzyme. Why?
• Presentation – 3 phases
• Severe acidosis, coagulopathy, renal failure, mental status changes and cerebral
edema can occur.

10. DRUG INDUCED LIVER INJURY
• Hepatotoxicity occurs within the first 6 months after drug initiation.
• commonly implicated  antibiotics, NSAIDs & anticonvulsants.
• herbal preparations, weight loss agents & other nutritional supplements cause
liver injury so inquiry about such substances should be included

11. CRITERIA FOR DILI

12. VIRAL HEPATITIS
• Hepatitis A – Usually self limiting infection
• Hepatitis B – Can occur as an acute infection or reactivation
• Hepatitis C - rare cause of ALF
• Hepatitis D, as a co-infection or super infection with HBV
• Hepatitis E – MCC of ALF in India. Severe in pregnant women.
• Atypical causes - HSV CMV EBV

13. AMANITA PHALLOIDES/MUSHROOM POISONING
• No available blood test to confirm diagnosis
• Suspected in patients with a history of severe GI symptoms (nausea, vomiting,
diarrhea, abdominal cramping) within hours to a day of ingestion.

14. WILSON DISEASE
• Uncommon cause
• young patients - abrupt onset of Coombs negative hemolytic anemia with
serum bilirubin levels >20 mg/dl.
• Kayser-Fleischer rings->50% patients
• Serum ceruloplasminlow
• Very low serum ALP & uric acid levels.
• High urinary & plasma copper levels
• A high bilirubin (mg/dl) to ALP (IU/L) ratio ( > 2.0) is a rapid (indirect) indicator.

15. BUDD CHIARI SYNDROME
• Acute hepatic vein thrombosis
• Abdominal pain, ascites and striking hepatomegaly
• Diagnosis confirmed with hepatic imaging studies (CT, Doppler
ultrasonography, venography,MRV) & testing to identify hypercoagulable
conditions (polycythemia,malignancies).

16. ACUTE ISCHEMIC INJURY
• Ischemic hepatitis: cardiac arrest; significant hypotension/hypovolemia;
severe CHF
• Transaminases often > 1000-2000 mg/dL;
• Simultaneous renal insufficiency and/or muscle necrosis often found

17. AUTOIMMUNE HEPATITIS
• Most severe form of the disease.
• New developed disease, exacerbation of chronic disease, or superimposed
injury on chronic disease.
• Auto-antibodies absent (30%)
• Liver biopsy should be considered if autoimmune hepatitis is suspected and
autoantibodies are negative.

18. ALF IN PREGNANCY
• AFLP is a rare condition caused by microvesicular fatty infiltration of
the hepatocytes owing to defects in the long-chain 3hydroxyacyl
coenzyme A dehydrogenase (LCHAD) in the fetalmitochondria.
• Third trimester or within a few days postpartum
• Increased fetal or maternal mortality.
• Elevated lactate despite adequate resuscitation and encephalopathy

19. • HELLP (Hemolysis, Elevated Liver Enzymes, Low Platelets) Syndrome.
• Triad of jaundice, coagulopathy, and low platelets.

20. CLINICAL MANIFESTATIONS
• Non specific initial symptoms - fatigue, malaise, anorexia, nausea, vomiting,
abdominal pain, lethargy.
• As the liver failure progress, patients develop jaundice, & may become
confused or eventually comatose.
• The presence of hepatic encephalopathy is one of the defining
characteristics of ALF.

22. DIAGNOSIS (history,physical examination,investigations)
• Date of onset of jaundice & encephalopathy.
• Alcohol abuse
• Medication use - prescription & recreational Herbal or traditional medicine
use
• Family hx of liver disease (wilson disease)
• Exposure to hepatic toxins (mushroom)
• Exposure to risk factors for viral hepatitis (travel, transfusion, sexual contacts,
occupation, body piercing)
• Evidence of complications (e.g renal failure,seizures, bleeding, infections)

23. PHYSICAL EXAMINATION
• Mental status examination & grading of HE
• Jaundice
• RUQ tenderness
• Hepatomegaly (viral hepatitis, malignant infiltration, CHF, Budd Chiari
syndrome)
• Rapid development of ascitis in ALF patient+ abdominal pain suggest the
possibility of BC syndrome.
• Clinical signs of elevated ICP (cushing triad & other neurologic changes such
as pupillary dilatation or decerebrate posture)

24. INVESTIGATIONS

25. TREATMENT
• General treatment
ABC
Fluid management
Correction of biochemical parameters
Monitoring- ABG, CBC, Biochemical parameters
• Treatment of specific etiology.
• Nutrition
• Infection – Surveillance and treatment.
• Management of complications.

26. ETIOLOGY SPECIFIC

27. CAUSE SPECIFIC TREATMENT
• Hepatitis A & E related ALF:supportive care
No virus specific treatment
• Hepatitis B:nucleoside and nucleotide analouges - prevents post transplant
reoccurrence
• Herpes virus /varicella zoster: acyclovir 5 to 10mg/kg IV evry 8hrs
• Consider transplant

28. ACETAMINOPHEN POISONING
• Life saving when administered within 24hrs of ingestion.
• NAC is best when given within 10 hours, its effects can still be of value within
72 hours of ingestion
• Oral and intravenous (IV) forms - similar efficacy .
• Oral NAC is given over 72 hours with a loading dose of 140 mg per kg and
subsequent doses of 70 mg per kg every 4 hours for a total of 17 doses.
• IV NAC preferred: 150 mg/kg loading dose,over 15-20mins
then 50 mg/kg over 4 hours, followed by 100/per kg over 16 hours.

29. DRUG INDUCED LIVER INJURY
• N-acetyl cysteine - helpful
• Immediate cessation of the suspected drug and supportive care
MUSHROOM POISONING:
• Start penicillin G and silibinin
• Most patients require LT

30. AUTOIMMUNE HEPATITIS:
• Patients with coagulopathy and mild hepatic encephalopathy
• Corticosteroid treatment (prednisolone 40-60mg/day)
• Perform liver biopsy and consider for LT
ISCHEMIC INJURY:
• Cardiovascular support is treatment of choice

31. ALF IN PREGNANCY:
• Immediate delivery of the baby
• LT if condition doesn’t improve post delivery
HEPATIC VEIN THROMBOSIS:
• Anticoagulation. TIPS. LT provided malignancy is excluded
WILSONS DISEASE:
Consider for LT ASAP

32. COMPLICATIONS

33. HEPATIC ENCEPHALOPATHY
• Spectrum of neurologic or psychiatric abnormalities resulting from liver
insufficiency and or portosystemic shunting.
• HE in acute liver failure – Cerebral edema with increased intracranial pressure
and risk of cerebral herniation
WEST HAVEN CRITERIA

35. • Ammonia – independent risk factor for development of intracranial
hypertension.
• Ammonia levels - >100 umol/L – severe encephalopathy
> 200 umol/L – Intracranial hypertension
> 122 umol/L for 3 days - high grade HE with low
rates of survival, high incidence of CE and seizures.
• ICP Monitoring –
Invasive – In grade III and IV encephalopathy
Normal ICP – 5 to 10mmhg
Maintain ICP around 15mmhg and CPP above 40mmhg
Non invasive – Transcranial doppler
Transcranial infrared spectroscopy
Jugular venous oximetry
Ultrasonic measurement of optic nerve sheath diameter.

36. MANAGEMENT –
• Evaluate and treat factors such as electrolyte abnormalities , bleeding and infection
• Cerebral edema – Elevation of head end – 30 degrees
Hypertonic saline or mannitol ( target sodium- 145-155mmol)
Corticosteroids – Dexamethasone
Hypothermia.
Definitive treatment – Liver transplantation
• Specific treatment of HE –
Lactulose
Rifaximin
Oral BCCA
L- ornithine L- aspartate
L – ornithine L - phenylacetate

37. RESPIRATORY COMPLICATIONS –
• ALI or ARDS
• Pulmonary edema
• Nosocomial pneumonia
• Trali
• Intra alveolar hemorrhage
• Treatment – Supplemental oxygen or endotracheal intubation
ACUTE KIDNEY INJURY –
• Common complication, poor prognostic indicator
• Causes – Hepato renal syndrome, acute tubular necrosis, drug toxicity, pre renal
azotemia
• Diagnosis of AKI – Monitoring urine output, volume status, measurement of urinary
sodium and creatinine
• Treatment – Avoid nephrotoxic drugs
RRT

38. COAGULOPATHY:
• Liver synthesizes coagulation factors and inhibitors including protein c, protein
s and thrombopoietin.
• In ALF, PT INR and APTT will be prolonged.
• Rebalanced hemostasis – Despite prolongation of measured INR or PT , they
have a normal coagulation state and significant proportion are
hypercoagulabe.
• Vit k and stress ulcer prophylaxis
• Platelets/FFP and recombinant factor VII(rFVIIa) only if active bleeding + or for
procedures.
• Platelet threshold – 10000 in the absence of bleeding, 50000 for invasive
procedures.

39. INFECTION :
• Due to dynamic immune dysfunction.
• Liver injury leads to activation of innate immune system, altered macrophage
and neutrophil function, initial activation and subsequent reduction of
complements, impaired phagocytosis and opsonisation resulting in functional
immunoparesis.
• Spill over phenomenon of chemotactic mediators and proinflammatory
cytokines – activates platelets, coagulation cascade, increase vascular
permeability and eventually SIRS.
• Most common organisms – Staphylococcus, streptococcus, Gram negative
organisms and candida species.
• Prophylactic antibiotics - controversial

40. HEMODYNAMIC INSTABILITY/RENAL FAILURE:
• Hyperdynamic circulation, low systemic vascular resistance and decreased peripheral
oxygen extraction ratio.
• Splanchnic and peripheral vasodilatation – systemic hypotension
• Norepinephrine – vasopressor of choice
• Vasopressin – Refractory hypotension.
• Cushing triad (hypertension, bradycardia and widened pulse pressure ) indicative of
intracranial htn.
METABOLIC:
• Hyponatremia, Hypophosphatemia
• Metabolic acidosis
• Lactic acidosis
• Hypoglycemia
• Treatment – Frequent glucose monitoring & administration of 25% Dextrose
Monitoring sodium, potassium, magnesium and phosphate levels.

41. PROGNOSIS
• Prognostic factors help in identification of patients who would benefit from
liver transplantation.
• Also help in identifying patients who may recover on own without need for
LT.
• SCORING SYSTEMS -
King’s college criteria
MELD
Clinchy criteria
APACHE
SOFA

42. PROGNOSTIC SCORINGS IN ALF

43. LIVER TRANSPLANTATION
• Only effective therapy for ALF patients who fail to recover spontaneously.
• King`s College criteria is used to select the patient that should be referred to a
transplant center for transplantation.

44. Criteria for liver transplantation

45. LIVER SUPPORT DEVICES
Bioartifical Artificial
Cellular component Yes No
Hepatic function derived All liver functions (Detoxification,
synthesis of proteins and regeration )
Only detoxification
Efficiency Promising results Limited
Ease of use Difficulty of maintaining cellular
components
Relatively easier
Cost High Relatively less
Examples Extra corporeal liver assist device
(ELAD)
Hepat Assist
Bioartificial liver support system
(BLSS)
Amsterdam medical centre
bioartificial liver (AMBCAL)
Molecular adsorbent recirculating
system (MARS)
Single pass albumin dialysis (SPAD)
Prometheus
Selective plasma filtration therapy
(SEPET)

46. ARTIFICIAL LIVER DEVICES
MARS
• Molecular adsorption and
recirculation system
• Adaptation of hemodialysis
• Blood is dialysed against 20%
albumin
• Shown to improve encephalopathy,
renal function and hemodynamic
parameters
• The efficacy of this technique has
not been studied
SPAD
• Single pass albumin dialysis
• Albumin solution across the
semipermeable membrane flowing
in counter directional flow
discarded after passing the filter.
• Detoxification capacity for
ammonia and bilirubin of SPAD is
higher as compared to MARS.
Prometheus (albumin is recycled) and sepet (albumin is discarded )need large pore
filters.

47. THANK YOU